Graduation Date

Spring 5-9-2026

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Programs

Epidemiology

First Advisor

Shinobu Watanabe-Galloway

Second Advisor

Edward Peters

Third Advisor

Cheng Zheng

Fourth Advisor

Don Coulter

Abstract

Background: Although financial hardship is multidimensional, pediatric oncology research has largely focused on material domain only, leaving gaps in behavioral and psychological domains and their impact on caregivers’ quality of life (QOL). Limited availability of validated FH instruments further constrains intervention development in this population. Method: This cross-sectional study recruited 166 caregivers of children diagnosed with cancer within the past five years from Nebraska Medicine and Children’s Hospital and Medical Center in Omaha, Nebraska. Poisson regression with robust variance was used to compare FH across socio-economic status (SES) profiles, linear regression with robust variances to assess FH associations with caregiver QOL, and exploratory and confirmatory factor analyses to evaluate the psychometric properties of the Comprehensive Score for Financial Toxicity (COST). Results: Material, behavioral and psychological FH were prevalent among caregivers, and differed across SES. For material FH, compared to high SES caregivers, middle SES caregivers reported a higher burden of inability to pay medical bills related to the child’s cancer diagnosis, household material hardship (HMH), and unpaid time off from work. In contrast, low SES caregivers reported a greater burden of HMH and higher rates of job quitting. Middle SES caregivers experienced a higher burden of psychological and behavioral FH than high SES caregivers. Conclusion: FH among caregivers in pediatric oncology is multidimensional. Screening and interventions should address behavioral and psychological FH in addition to material hardship to improve caregiver well-being and cancer outcomes for children.

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